U.S. Global Health Priorities: USAIDs Global Health FY2003 Budget

Report for Congress
U.S. Global Health Priorities:
USAID’s Global Health FY2003 Budget
Updated March 18, 2003
Tiaji Salaam
Analyst in Foreign Affairs
Foreign Affairs, Defense, and Trade Division

Congressional Research Service ˜ The Library of Congress

U.S. Global Health Priorities:
USAID’s Global Health FY2003 Budget
Summary
Global health has become a major focus of the U.S. foreign assistance program.
Congressional proponents of more health assistance have successfully increased
appropriations above Administration requests in recent years. Some have challenged
the Administration’s FY2003 budget proposal during the foreign operations debate,
particularly the manner in which the Administration proposed the United States
Agency for International Development (USAID) allocate its funds. It requested a $36
million increase in FY2003 for global health programs. It proposed that more than
40% of the global health budget be spent on HIV/AIDS activities, up substantially
from the previous fiscal year. USAID emphasized that HIV/AIDS affects all sectors
of societies, and thus it is a priority in global health. Some in Congress have
expressed concern about the consequences of spending a significant portion of global
health funds on HIV/AIDS, and suggested that more money be spent on other
programs, namely infectious diseases and child survival. As Congress debated
funding levels for FY2003 global health activities it discussed several issues
including: global health funding versus other development assistance programs, and
increasing funding to HIV/AIDS at the expense of other global health programs.
This report will be updated as needed.

Contents
Most Recent Developments..........................................1
HIV/AIDS Activities.......................................1
Other Infectious Diseases....................................1
Family Planning/Reproductive Health..........................2
Background ......................................................2
USAID Global Health Priorities......................................7
Issues and Options for Congress......................................8
Adequacy of Global Health Budget................................8
Global Health Versus Other Development Assistance.................9
HIV/AIDS Versus Other Global Health Programs...................10
Number of Directives in Global Health Programs....................12
List of Figures
Figure 1. Total Allocations for Global Health
(in millions of dollars)..........................................6
Figure 2. HIV/AIDS Spending in Global Health Budget
(in millions of dollars)..........................................7
List of Tables
Table 1. Child Survival and Health (CSH) Programs Fund.................1
Table 2. USAID Global Health Programs...............................4

U.S. Global Health Priorities:
USAID’s Global Health FY2003 Budget
Most Recent Developments
On February 12, 2003, Congress passed the Consolidated Appropriations
Resolutions, 2003, P.L.108-7. The bill includes funding for USAID global health
activities at the following levels:
Table 1. Child Survival and Health (CSH) Programs Fund
ProgramAccountFunding Level
Child Survival & MaternalChild Survival and Health Fund$ 324,000,000
Healthof which Polio-$27,500,000
Vulnerable ChildrenChild Survival and Health Fund$ 27,000,000
Bilateral HIV/AIDS ProgramChild Survival and Health Fund$ 591,500,000
- including Microbicides - $18,000,000
- including Vaccine Fund - $60,000,000
- including International - $10,500,000
AIDS Vaccine Initiative
- including International - $100,000,000
Mother & Child HIV
Prevention Initiative
Other Infectious DiseasesChild Survival and Health Fund$ 155,500,000
Family Planning/ReproductiveChild Survival and Health Fund$ 368,500,000
Health
UNICEFChild Survival and Health Fund$ 120,000,000
Global Fund to Fight AIDS,Child Survival and Health Fund$ 250,000,000
Tuberculosis and Malaria
GRAND TOTALChild Survival and Health Fund$1,836,500,000
HIV/AIDS Activities. The omnibus bill appropriates a total of $800 million
for USAID HIV/AIDS activities. However, the $591.5 million listed above is
allocated for the Child Survival and Health (CSH) Programs Fund. Another $38.5
million is provided through other USAID-managed or co-managed accounts, and
$170 million is reserved for the Global ATM Fund and UN agencies. P.L. 108-7
reserves an additional $100 million for the Global Fund through the Labor, HHS, and
Education Appropriation, bringing the total United States contribution to the Global
Fund to date to $725 million.
Other Infectious Diseases. Congress reserves a total of $120 million for
tuberculosis assistance in the FY2003 omnibus appropriations bill. Of this amount,

$65 million is funded through the CSH account, $15 from other bilateral accounts
and $40 million through the Global Fund contribution. A total of $115 million is
appropriated for malaria assistance, with $65 million directed to the CSH account,
$7.5 million designated to other bilateral accounts and $42.5 million through the
Global Fund contribution.
Family Planning/Reproductive Health. A total of $446.5 million is made
available for family planning/reproductive health from all accounts, with $368.5
million reserved for the CSH account.
Background
The Administration gave priority to HIV/AIDS in its budget request for USAID
programs. In its FY2003 global health budget proposal it dedicated more than 40%
of its funding to HIV/AIDS activities, while decreasing spending in most of the other
health programs. Some Members of Congress expressed concern that reserving a
significant portion of the global health budget for HIV/AIDS activities without
increasing overall global health funding would have left other health programs
without enough funds. Meanwhile, USAID maintained that in practice the increase
in the overall global health budget was more important than the program in which the
funding changes occurred.¹ Additionally, it asserted that its integrative approach
would minimize the impact of the lower budget allocations on the other health
programs. This report examines U.S. global health funding trends since 1999,
reviews issues surrounding USAID’s decision to funnel much of its money into
HIV/AIDS activities, and analyzes current global health spending priorities.
Global health activities have become a major component of U.S. foreign aid,
partially due to growing concern among some policy makers that health could
significantly impact economic growth, national security, and political stability in
many parts of the world. According to a 2000 CIA report, The Global Infectious
Disease Threat and Its Implications for the United States, the persistent infectious
disease burden is likely to increase the risk of economic decay, social fragmentation,
and political destabilization in the hardest hit countries in the developing and former
communist worlds.² The report further indicates that the economic costs of infectious
diseases, especially HIV/AIDS and malaria, are already significant and will take a
heavy toll on productivity, profitability, and foreign investment, possibly reducing
GDP by as much as 20% or more by 2010 in some sub-Saharan African countries.³
Infectious diseases could significantly affect not only those abroad, but also
Americans at home. According to the CIA report, over the last 30 years, twenty well
known diseases, including TB, malaria and cholera, have reemerged or spread

¹ U.S. House of Representatives Subcommittee on Foreign Operations Hearing, March 13,

2002, p.6.

² The Global Infectious Disease Threat and Its Implications for the United States
[ ht t p: / / www.ci a.gov/ ci a/ publ i cat i ons/ ni e / r epor t / ni e 99-17d.ht ml ] .
³ Ibid.

geographically, often in more virulent and drug-resistant forms. Furthermore, at least
30 previously unknown incurable diseases have emerged since the 1970s. Although
infectious diseases do not pose as great of a threat to American security as they do
for other countries they could still have a significant impact. Many infectious
diseases, most recently, the West Nile virus, originate outside U.S. borders and are
introduced by international travelers, immigrants, returning U.S. military personnel,
or imported animals and foodstuffs. The CIA report predicts that the most dangerous
known infectious diseases likely to threaten the United States over the next two
decades will be HIV/AIDS, hepatitis C, TB, and new, more lethal variants of
influenz a.⁴
U.S. health programs, for many years, have included programs that aim to
thwart the spread of infectious diseases, address the disastrous effects of HIV/AIDS,
and bolster the crumbling health infrastructures of many developing countries.
Members of Congress have become increasingly aware of the potential dangers of the
spread of infectious diseases. Consequently, the priority placed on global health
funding within the broad scope of foreign aid has increased significantly since the
mid 1990s. Congress has been especially supportive, and in many cases the initiator,
of increased health spending.
USAID is the U.S. agency primarily responsible for implementing international
health programs. The global health pillar, one of USAID’s four program pillars,
covers a range of health programs and resources whose funding came from
preexisting accounts that funded child survival and disease activities. Those accounts
are:
^!Child Survival and Health Programs Fund (CSH)
^!Economic Support Fund (ESF)
^!Assistance for Eastern Europe and the Baltic States (AEEB)
^!Assistance for the Independent States of the Former Soviet Union
(FSU)
^!P.L. 480 Title II Food Aid (PL 480)
Table 2 shows the funding levels of USAID global health programs since 1999.
As the table illustrates, while the global health program is funded through a number
of sources most program activities are financed through the Child Survival and
Health Programs Fund (CSH). Nearly 90% of the global health budget comes from
the CSH account. CSH is the most significant part of the global health budget, and
consistently receives bicameral and bipartisan support in Congress.

⁴ Ibid.

Table 2. USAID Global Health Programs
(in millions of dollars)
Child Survival and HealthEnactedEnactedEnactedEnactedEstimate
F und F Y 1999 F Y 2000 F Y 2001 F Y 2002 F Y 2003
Child Survival & Maternal Health312^a280295320324
Vulnerable Children--152527
HIV / AIDS 135 175 404 445 591.5^b
Global Fund^c--100^d50250^e
Other Infectious Diseases5062124155155.5
Family Planning & Reproductive
Health 335 328 376 369 368.5
UNICEF 105 110 110 120 (120)
Subtotal 937 955 1,324 1,434 1,836.5
ESF, FSA, AEEB, PL 480FY1999FY2000FY2001FY2002FY2003^a
Child Survival & Maternal Health91187666360
Vulnerable Children--77-
HIV / AIDS 4 2 1 2 8 4 0 38.5
Other Infectious Diseases148161322.5
Family Planning and
Reproductive Health4645487815
UNICEF-----
Subt ot al 155 261 165 201 136
All AccountsFY1999FY2000FY2001FY2002FY2003^a
Child Survival & Maternal Health403467361383384
Vulnerable Children--223227
HIV / AIDS 139 196 433 485 800^f
Global Fund--10050250
Other Infectious Diseases6470140168178
Family Planning and
Reproductive Health381372424447383.5
UNICEF 105 110 110 120 -120
GRAND TOTAL10921216148916351972.5
^Source:^U^S^A^I^D^Bu^dg^et^O^f^fⁱ^{ce, A}^p^ri^l^{15, 2002.}
^a^In^clu^d^es^{$50 m}^illion^s^u^pplem^en^tal.
^b^{FY2003 in}^clu^d^es^{$100 m}^illion^f^o^{r th}^{e In}^tern^ation^a^{l Moth}^{er an}^{d C}^h^{ild HIV P}^r^ev^en^tion^In^itiativ^e.
^c^Glo^b^a^{l Fu}ⁿ^d^coⁿ^t^rⁱ^b^u^tioⁿ^s^oⁿ^ly^r^e^f^l^ect^f^uⁿ^d^s^allo^cated^to^USA^I^{D. T}^h^{e f}^u^{ll Glo}^b^a^{l Fu}ⁿ^d^coⁿ^t^rⁱ^b^u^tioⁿ
ⁱ^s^at^t^rⁱ^b^u^t^{ed t}^o^H^I^V^/^A^I^D^S^t^o^t^a^l^sⁱⁿ^fⁱ^s^cal^y^ears²⁰⁰¹^an^{d 2002. H}^o^w^e^v^e^{r, i}ⁿ^F^Y^{2003, on}^l^y^$170
^m^illioⁿ^o^f^th^{e Glo}^b^a^{l Fu}ⁿ^d^coⁿ^t^rⁱ^b^u^tⁱ^oⁿ^dⁱ^r^ected^to^HI^V/A^I^{DS activ}^{ities is in}^clu^d^edⁱⁿ^th^e
^HIV/A^I^{DS to}^tal.^d
^T^h^{e $100 m}^illion^w^a^s^f^uⁿ^d^{ed th}^ro^{ugh t}^h^e^{2001 S}^u^ppl^em^en^t^a^l^A^ppropri^a^tⁱ^oⁿ^s^.^e
^A^ccordin^g^{to th}^{e FY 2003 om}ⁿⁱ^bu^s^{appropriation}^s^b^{ill, con}^t^ribu^tion^s^{to th}^{e Global Fu}ⁿ^d^are^to^be
^divi^d^e^d^b^e^tw^een^HIV/A^I^{DS($170 m}^illion⁾^{, m}^a^{laria ($42.5 m}^illion⁾^an^{d tu}^bercu^l^os^is^($40
^m^illion⁾^{. A}^ddition^a^{l con}^t^ribu^tioⁿ^s^h^a^v^e^been^m^a^{de to th}^e^{Global Fu}ⁿ^d^tota^lin^g^{$650 m}^illion^to
^dat^e^{. F}^o^{r m}^o^{re i}ⁿ^f^o^rm^atⁱ^oⁿ^on^G^l^obal^F^uⁿ^d^con^t^ri^bu^tⁱ^oⁿ^s^s^{ee C}^R^S^R^e^port^R^L^31712.^f
^In^clu^d^es^{$170 m}^illion^{Global Fu}ⁿ^d^con^t^ribu^tion^f^o^{r HIV/A}^I^DS.

The Child Survival and Health Programs Fund, created in FY1996, is an account
that funds a compilation of global health programs that enhance the likelihood of
child survival, address maternal health concerns and curb the spread of infectious
diseases. The CSH was created when there was significant pressure to cut foreign
aid spending as part of the overall effort to eliminate the federal budget deficit.⁵ In
an effort to protect the most vulnerable populations in the poorest parts of the world
the House Subcommittee on Foreign Operations, Chaired by Representative Sonny
Callahan, added language that would introduce the Child Survival and Disease Fund
into the Foreign Operations appropriation legislation. The objective was to ensure
that there would be no reductions in programs that directly affect younger children,
and to accelerate efforts to eradicate diseases that threaten younger children.⁶
Funding for CSH was derived from preexisting child survival and adult disease
accounts. Those accounts were:
^!The Development Assistance Fund (DA);
^!The Development Fund for Africa (DFA);
^!The Economic Support Fund (ESF);
^!Assistance for Eastern Europe and the Baltic States (AEEB);
^!Assistance for the New Independent States of the Former Soviet
Union (FSU);
^!and the UNICEF portion of International Organizations and
Programs. ⁷
Initially, the Child Survival and Health Programs Fund (originally called the
Child Survival and Disease Programs Fund) account did not include reproductive
health and population activities, and included basic education for children’s
initiatives. Education programs are no longer part of the CSH account, while
reproductive health and population programs have been added. Currently, CSH is
used for activities related to:
^! immuniz ations;
^!oral rehydration;
^!health and nutrition;
^!water and sanitation;
^!a grant to UNICEF;
^!displaced and orphaned children;
^!reproductive health and population activities;
^!the treatment, prevention and research for tuberculosis, HIV/AIDS,
polio, malaria and other diseases;⁸
^!and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.

⁵ Interview with Staffer, U.S. House of Representatives Committee on Appropriations, April

12, 2002.

⁶ U.S. House of Representatives Subcommittee on Foreign Operations Committee Report:
H.Rept. 104-143, June 15, 1995, p. 12.
⁷ Ibid, p. 16.
⁸ Foreign Operations Conference Report: H.Rept. 107-345, December 19, 2001, p. 3.

Figure 1 illustrates the trend in CSH and global health funding since 1999.
Although CSH is only one part of the global health budget it has become a significant
part, receiving bicameral and bipartisan support in Congress. It accounts for more
than 90% of the FY2002 global health budget. Since it was created in FY1996,
allocations for CSH have increased from $592.6 million to $1.836 billion in FY2003.
When combined with funds from all accounts, including CSH, funding for the global
health budget reached $1.972 billion in FY2003.
For FY2003, the Administration did not request CSH funds. Instead, it
requested that $1.594 billion of the global health budget (ordinarily funded through
CSH) be funded through development assistance. It requested that the remaining
$177 million come from the other accounts, bringing the total global health budget
request to $1.771 billion. USAID argued that funding the global health programs
through the development assistance account would give it greater flexibility in
project implementation. As in past years, the Administration requested the FY2003
UNICEF contribution through the international organization contributions rather than
global health funds. Congress has challenged both of these decisions. Protecting the
Child Survival and Health Programs Fund and maintaining UNICEF contributions
have remained a high priority for many in Congress. Consequently, funding for
global health programs and UNICEF were placed under the Child Survival and
Health Programs account for FY2003 in the Senate and House Foreign Operations
bills.

Figure 1. Total Allocations for Global Health
⁽ⁱ^{n m}^illions^of^dollar^s⁾

USAID Global Health Priorities
The Administration request for FY2003 includes a significant increase in
HIV/AIDS spending and a decrease in nearly all of the other health programs. Figure
2 illustrates the rate at which HIV/AIDS spending has increased relative to the other
health programs. In FY1999, USAID spent 12.7% ($139 million) of its global health
budget on HIV/AIDS. In FY2002, USAID spent 29.7% ($485 million) of its global
health budget on HIV/AIDS activities. Finally, in FY2003, 40.6% ($800 million) of
the USAID global health budget was reserved for HIV/AIDS activities, including
$100 million for the President’s new initiative, the International Mother and Child
HIV Prevention Initiative. The FY2003 appropriation increased HIV/AIDS spending
nearly 40% within one fiscal year. If Congress had approved the Administration’s
request, the budget share of other programs would have fallen 28% from FY1999
spending levels and 11% from FY2002 spending levels. All figures include Global⁹
Fund contributions.
Figure 2. HIV/AIDS Spending in Global Health Budget
⁽ⁱ^{n m}^illions^of^dollar^s⁾
The Administration maintained that it is committed to global health. Although
it proposed cutting spending in some of the global health categories, USAID argued
that it had to set priorities within a budget with limited room for expansion.
Consequently, it had to balance health and non-health areas of international

⁹ The full Global Fund contribution is applied to HIV/AIDS funding in fiscal years 2001 and
2002. However, only the $170 million of the Global Fund Contribution that Congress
directed to HIV/AIDS activities is included in total HIV/AIDS figures.

assistance. USAID officials say that $740 million for HIV/AIDS, as determined by
the Office of Management and Budget (OMB), was the appropriate level to support
the President’s commitment to countering the global spread of HIV/AIDS. USAID
reiterated that it continues to support international health programs, including those
for child survival and maternal health, vulnerable children, and other infectious
diseases. Although the Administration proposed that some of the funds for those
programs be reduced in FY2003, USAID maintained that it would strive to minimize
the impact of the reductions by focusing on populations most in need, and by
leveraging other donors.¹⁰
Instead of focusing on the cuts in some programs USAID argued that the most
important thing to concentrate on is the integrative nature of the programs, and that
overall spending on global health would increase. On March 13, 2002, USAID
Administrator Andrew Natsios testified before the House Foreign Operations
Subcommittee. During that hearing Mr. Natsios stated,
There are a number of things we do in HIV/AIDS which is also something we do
in maternal health and in child survival. For example, a mother that has a
sexually transmitted disease that is pregnant has a very high risk of the kid dying
when the child is born. The survival rate dramatically drops if the woman has
an STD when she’s pregnant. So part of our child survival strategy is STD
strategy. That’s also part of our HIV strategy. So a lot of these programs in the
field are actually integrated together and they have to be or they don’t work...
The important factor I would point out here in all of these health accounts is the¹¹
bottom line is up $60 million. And so there’s $60 million more being spent on¹²
health programs than there were before. And I think that’s a good message.
Issues and Options for Congress
In its deliberations over the FY2003 appropriations for global health in the
foreign operations bill, Congress considered a number of issues, including: the
adequacy of the global health budget, global health funding versus other development
assistance, HIV/AIDS spending versus other global health programs, and the number
of directives in global health programs.
Adequacy of Global Health Budget
Given the trade-offs that proposed funding levels for global health seemed to
face, were proposed funding levels adequate to meet U.S. health objectives? As

¹⁰ Interview with USAID, April 12, 2002.
¹¹ The $60 million increase that Mr. Natsios refers to only considers the Child Survival and
Health Programs Fund account and excludes the UNICEF contribution. The FY2003
request for the Child Survival and Health Programs Fund, which does not include the
UNICEF grant, totals $1.374 billion. The equivalent total for CSH in FY2002, excluding
the $120 million to UNICEF, is $1.314 billion, leaving a difference of $60 million.
¹² U.S. House of Representatives Subcommittee on Foreign Operations Hearing, March 13,

2002, p.22.

HIV/AIDS continues to ravage developing countries and emerging states, the
Administration deemed it vital to place a substantial amount of resources into
activities that counter the spread of HIV/AIDS. Some at USAID argued that overall
funding for global health activities is not sufficient to meet all the needs in the field.
They said that it is often difficult to balance competing priorities within the global
health budget. Consequently, they say that the size of the global health budget
necessitates that as funding increases in one program area it decreases in others.
On February 12, 2003, Congress passed P.L. 108-7, an FY2003 omnibus
appropriations bill, which included $1.84 billion for CSH and $1.97 billion for
USAID global health activities. Most global health programs (except family
planning and reproductive health initiatives) were funded above requested levels.
The increase was most significant for HIV/AIDS. Directed funds include $800
million for the fight against HIV/AIDS. This figure is $140 million above the
Administration’s request of $740 million, and includes the President’s $100 million
request for the International Mother and Child HIV Transmission (MTCT) initiative
on September 3, 2002.¹³ The HIV/AIDS funds also include $170 million of the $250
million Global Fund contribution. $384 million is directed for maternal and child
health activities, the Administration requested $344 million. The President only
requested $122 million to fight other infectious diseases, while Congress set aside
$178 million. Congress directed $383.5 million to fund family planning and
reproductive health activities, $41.5 million below the $425 million request from the
Administration. Finally, the Senate Appropriations Committee voted to give $120
million to the United Nations Children’s Fund (UNICEF) through the CSH account
although the Administration did not request funding for UNICEF under the account.
The omnibus bill also reserves an additional $100 million for the Global Fund
through the Labor, HHS, and Education Appropriation, allocating $350 million in
total for the Global Fund.
Global Health Versus Other Development Assistance
Do current global health funding levels affect the implementation of other
development assistance programs? Some are concerned with what they perceive as
an overemphasis on global health vis-à-vis other development programs. In FY2002,
health programs accounted for about 60% of all development assistance.¹⁴ Critics
believe that other areas also need support, namely education, democracy, trade and
investment, and agriculture. These areas also significantly impact development and
health, critics argue. Some claim if the programs that build human capacity, promote
stable governments, encourage private investment and foster environmentally-
friendly growth are not simultaneously supported, then the health programs will not
be sustainable.
This issue has been raised during some of the Foreign Operations hearings.
USAID Administrator Andrew Natsios noted that while agriculture is vital in
countering poverty and supporting health programs, the trend has been to reduce

¹³ see, p.11.
¹⁴ Interview with USAID staff, April 12, 2002.

funding to agricultural programs as other issues, such as HIV/AIDS and famines
demand immediate responses. “[T]he only way you’re going to reduce poverty in the
world and reduce hunger is not by constant humanitarian programs, but by teaching
people how to grow more food. And we’re not doing that because all of the money
has been shifted to accounts where there is more and legitimate interest.”¹⁵ “If you
have child survival projects and you keep kids alive until they’re 5 years old – you
know what happens after 5? They become malnourished, because the parents are still
so poor they can’t provide for them. We should look at the countries where we have
child survival programs for older kids to see what the malnutrition rates are. They
have been disturbingly high.”¹⁶ U.S. Representative Jerry Lewis conceded that
agriculture does impact poverty reduction, good governance, and a host of other
development issues. “[I]ndeed, I’ve felt for many, many years it’s very difficult to
talk to developing countries about democracy and freedom and peace, and indeed
terrorism, if their children go to bed with their stomachs hurting every night.”¹⁷
Although some may like to see some of the foreign assistance money spent on
other development assistance activities, Chairman Kolbe described the difficulty that
many in Congress faced while considering the President’s request. “If Congress fully
funds the HIV/AIDS request that the president has made, it’s going to have to be
something reduced somewhere else: economic growth, agriculture, trade. That
happens, the advocates of trade promotion, basic education, microcredit, all of which
are represented before this committee, are going to face some tough choices. [T]he
question is, if we go complete funding of what there’s a huge amount of public
pressure now to do...the other kinds of things in agriculture, trade promotion are
going to likely suffer.”¹⁸ The FY2003 Omnibus Appropriations bill, P.L. 108-7,
funded most global health programs above requested levels. Although it is unclear
whether family planning programs were funded below requested levels to fund
increases in other global health programs, some requests for cuts have been made in
other areas.¹⁹
HIV/AIDS Versus Other Global Health Programs
How does funneling a significant portion of the global health budget to
HIV/AIDS programs affect the other health programs? Historically, Congress has
placed heavy emphasis on halting the spread of infectious diseases, particularly those
that are becoming increasingly antimicrobial resistant. It has maintained its support
for infectious diseases, and has funded the programs above requested levels. In
FY1998, the Senate and House Subcommittees on Foreign Operations expressed
concern that USAID had not placed enough emphasis on combating the spread of

¹⁵ U.S. House Subcommittee on Foreign Operations Hearing, May 17, 2001, p. 47.
¹⁶ Ibid, March 13, 2002, p.29.
¹⁷ Ibid, p.30.
¹⁸ Ibid, p.26.
¹⁹ For more information on the foreign operations bills see CRS Report RL31311.

infectious diseases.²⁰ Recognizing the correlation between HIV/AIDS and TB, in
FY2001, the House and Senate Subcommittees on Foreign Operations urged USAID
to increase its activities related to HIV/AIDS and TB prevention, as well as those that
seek to treat and prevent sexually transmitted diseases. They also recognized the
promising results of microbicide research and urged USAID to increase its work in
that area.²¹ Still later the House Subcommittee on Foreign Operations expressed
concern in FY2002 that USAID had not placed enough emphasis on halting emerging
epidemics.²² Finally, in FY2002, the Senate Subcommittee on Foreign Operations
added that USAID should seek to provide resources to build the capacity of
governments to effectively use additional funds for the prevention and treatment of
HIV/AIDS programs so that they can reach people in need.²³
Not only are some in Congress particularly concerned about the spread of
infectious diseases, but they are also concerned about the other programs in global
health. At the hearing on the USAID budget proposal for FY2003, some Members
expressed concern about the impact of increasing spending on HIV/AIDS activities
at the expense of other global health programs. Representative Jesse Jackson stated,
“I am concerned with what the Administration has proposed to this subcommittee
regarding international health. The Administration’s budget cuts funding for TB,
malaria, and child survival programs, all programs I believe Congress strongly
supports, and wraps up the stand-alone child survival and health account, created by
my good friend from Alabama, Sonny Callahan, into development assistance
accounts. I think some of the increases we are making in our bilateral contributions
for HIV/AIDS is a good first step. But, it seems to me that we are simply robbing
Peter to pay Paul. Could you explain to us why we’re not growing all the global
health accounts equally?”²⁴
Although many in Congress also deem countering the spread of HIV/AIDS a
priority, they differ from the Administration in that they do not want to boost
HIV/AIDS funding at the expense of other health programs. Congressional support
for HIV/AIDS programs is illustrated by the inclusion of additional funding for
HIV/AIDS through the FY2002 supplemental, H.R. 4775.²⁵ After passing the House
on May 24, 2002, and later the Senate on June 6, 2002, the FY2002 Supplemental
Appropriation became Public Law 107-206 on August 2, 2002. The $28.9 billion bill
included $200 million to fight HIV/AIDS with at least $100 million reserved for the
Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.

²⁰ U.S. Senate Subcommittee on Foreign Operations Report: S.Rept. 105-35, June 24, 1997,
p. 9.
²¹ U.S. House of Representatives Subcommittee on Foreign Operations Committee Report:
H.Rept. 106-720, July 10, 2000, p. 18.
²² U.S. House of Representatives Subcommittee on Foreign Operations Report: H.Rept. 107-

142, July, 17, 2001, p.11.

²³ U.S. Senate Subcommittee on Foreign Operations Committee Report: S.Rept. 107-58,
September 4, 2001, p. 11.
²⁴ U.S. House of Representatives Subcommittee on Foreign Operations Hearing, March 13,

2002, p.21.

²⁵ H.R.4775, p.28.

The additional $200 million for HIV/AIDS was part of a $5.1 billion
contingency emergency package that was attached to the supplemental bill. As
provided by P.L. 107-206, the President had until September 1, 2002, to decide
whether to obligate all of the funds or spend none of it.²⁶ At an economic forum held
in Waco, Texas on August, 13, 2002, the President announced that he would not
obligate the contingency funding because he felt that the government needed to
practice fiscal discipline. Some Democrats reportedly said that they perceived the
action as “a White House effort to portray the withholding of the funds as a struggle
between the President and Democrats, even though the appropriations had broad
Republican support.”²⁷ Critics also accused the President of blocking funding to his
own programs. The President acknowledged that he supported some of the initiatives
in the contingency package, however he said that he would request support for his
priorities, including HIV/AIDS from the FY2003 appropriations.
On September 3, 2002, the President proposed changes to the FY2003
Department of Health and Human Services (HHS) Appropriations and the Foreign
Operations Appropriations to request $200 million for his new initiative, the
International Mother and Child HIV Prevention Initiative. The President requested
that the money be shared equally between HHS and the USAID. Congress funded
this initiative in FY2003. P.L. 108-7 includes $140 million for the new initiative.
$100 million comes from USAID funds and the remaining $40 million is drawn from
HHS funds.
Number of Directives in Global Health Programs
How do congressional directives affect the United States’ ability to adjust health
assistance programs to match the conditions in the field quickly? In an attempt to
demonstrate the impact of the directives, representatives from USAID stated that only
$207 million, the portion of the FY2002 global health budget designated to reduce
the main causes of child mortality and morbidity, does not contain specific directives
as to the allocation of funds. They reported that it is not the large directives that
significantly impact the global health programs, rather it is the small ones that
become substantial when totaled.²⁸
Legislative directives have become more specific as Congress has become
increasingly concerned about global health issues. When global health programs first
began Congress offered few directives. As criticisms about the effectiveness of
foreign aid mounted, Congress began to clearly earmark areas of high priority,
ultimately leading to the creation of the Child Survival and Health Programs Fund.²⁹

²⁶ The debate surrounding the supplemental bill is discussed further in CRS Report
RL31406.
²⁷ Arizona Daily Star, “Bush won’t spend $5.1B Congress OK’d.” August 15, 2002, p.1.
[ h t t p : / / www.azst ar net . com/ st ar / wed/ 20814NBUSH-SPEND-NYT .ht ml ]
²⁸ Interview with USAID staff, April 12, 2002.
²⁹ Interview with Staffer, U.S. House Committee on Appropriations, April 12, 2002.

Although the Administration has expressed dissatisfaction with the level of
congressional directives, Congress attached directives to the FY2003 global health
budget, as it has in the past, to ensure that its spending priorities are protected.
Chairman Kolbe’s comments during Secretary Powell’s hearing in February 2002
illustrate divergent spending priorities in the global health budget between Congress
and USAID. “This budget would increase funding for AIDS so rapidly that it calls
for sharp cutbacks in maternal health, child survival, and the equally critical struggle
against resurgent tuberculosis and malaria.”³⁰ Directives have remained in the
FY2003 global health budget this fiscal year, and may continue in the future to the
extent that Congress’ spending priorities differ from those of USAID.

³⁰ U.S. House of Representatives Subcommittee on Foreign Operations Hearing, February

13, 2002, p.2.